ML20079B910
| ML20079B910 | |
| Person / Time | |
|---|---|
| Site: | Wolf Creek  |
| Issue date: | 12/30/1994 |
| From: | Maynard O WOLF CREEK NUCLEAR OPERATING CORP. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| WO-94-0220, WO-94-220, NUDOCS 9501090153 | |
| Download: ML20079B910 (8) | |
Text
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i W$LF CREEK
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NUCLEAR OPERATING CORPORATION December 30,-1994 Otto L Maynard Vce President Plant operations T
U. S. Nuclear Regulatory Commission ATTN: Document Control Desk Mail Station P1-137 Washington, D.
C.
20555 f
Reference Letter dated November 16, 1994, from T. P.
- Gwynn, NRC, to N. S.
Carns, WCNOC
Subject:
Docket No. 50-482: Reply to Notices of Violation 482/9413-01 and'-02 Gentlemen:
Attached is Wolf Creek Nuclear Operating Corporation's (WCNOC's) Reply to Notices of Violation 482/9413-01,
-02, which were documented in the Reference (NRC Inspection Report 50-482/94-13).
Violation 482/9413-01 concerned WCNOC's failure to iss'te a charter and plan
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for Incident Investigation Team 94-05 as required by prwedure.
Violation 482/9413-02 concerned WCNOC's failure to implement corrective action requiremsnts in accordance with 10 CFR 50, Appendix B, Criterion XVI.
WCNOC's response to these Notices of Violation is in the Attachment to this letter.
The corrective actions for these violations are comprehensive and will ensure WCNOC's compliance with the applicable regulations and procedural l
requirements. This violation response is being submitted after the thirty day due date with the concurrence of D.
D.
Chamberlain, NRC Branch Chief Re. actor Projects B Region IV, per a telecon on December 12, 1994, with T. M. Damashek, f
Supervisor Regulatory Compliance at WCNOC.
If you should have any questions regarding this response, please contact me at (316) 354-8831, extension 4450, or Mr. R. D.
Flannigan at extension 4500.
Very truly your m
i N
Otto L. Maynard OLM/jad Attachment cc:
L. J. Callan (NRC), w/a D. D.
Chamberlain (NRC), w/a J.
F.
Ringwald (NRC), w/a T
i J.
C.
Stone (NRC), w/a aO B x 411/ Burtingt n. KS 66839 / Phone (316) 364-8831 g
9501090153 941230 PDR ADOCK 05000482 An f qual Opportunity Ernployw M MC/VE1
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PDR L
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Attachment'to WO 94-0220 Page 1-Rapiv to Motices of violation 9413-01. -02 F
Violation 482/9413-01:
Failure to issue a charter and plan for Incident' Investigation Team 94-05 as required by procedure.
- A.
Criterion V of Appendix B to 10 CFR 50 requires, in part, that activities affecting quality shall be prescribed by documented instructions, procedures, and drawings appropriate to the circumstances. and shall be accomplished in accordance with these instructions, procedures and drawings.
Licensee Procedure AP. 34E-
- 001, Self Assessment Process," ' Revision 0,
is the implementing.
procedure for team investigation of significant events at the Wolf Creek Generating Station.
Procedure AP 34E-001 requires, in part, that team investigations of significant events or conditions be chartered by the applicable vice-president.. The procedure also requires the development of a written investigation plan encompassing purpose, scope, methodology, and schedule of the investigation.
Contrary to the above, the licensee team investigation effort, initiated on October 11, 1994, to resolve the consequential failure of both emergency diesel generator static exciter-voltage regulators was not chartered until October 18, 1994, after inspectors had twice l
requested a copy of the charter.
In addition, a written plan directing the investigation was never developed and implemented."
Admission of violations l
WCNOC agrees that a failure to follow the procedure occurred, in that WCNOC did not issue a charter or plan for Incident Investigation Team (IIT) Report 94-05.
l as required by procedure AP 34E-001, "Self Assessment."
j l
Raason for violationt l
J Root cause In accordance with procedure KGP-1209, " Root Cauce Analysis," Revision 1,
a j
formal review was conducted utilizing a' combination of Barrier Analysis, cause i
Level Analysis considerations, and Human Performance Enhancement System (HPES) techniques.
i The root cause of this Violation is cognitive personnel error, in that a review i
of prior IIT-type activities demonstrates that charters have always been issued i
for an IIT at or about the time of initiation of the investigation.
Formal p?ans, however, have not been issued (for IITs) in the past, although they are specifically prescribed by procedure AP 34E-001.
This requirement was added to AP 34E-001, when WCNOC merged KGP-1205, "Self Assessment" and ADM 01-116,
" Incident Investigation" in April 1994.
Responsible personnel involved in IITs j
were unaware of or misunderstood this requirement to issue a formal written plan directing the investigation.
The root cause of this portion of the viol.ation j
is, therefore, a failure to ensure that personnel were aware of and understood the administrative procedural requirements.
)
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1 Attcchment to WO 94-0220 i
Page 2 Contributina Factors
- 1. The Vice President Plant Operations had discussed the details of the IIT with the Vice President Engineering (who was assigned as the team leader with overall responsibility for the conduct of the IIT 94-05 evaluation) in advance of the initiation of the investigation.
Due to heightened concerns over emergency diesel generator (EDG) operability, the potential consequences of in-operability during refueling outage conditions present at the time, and the high level of management involvement in the cetual investigation, the IIT members belisved they had received sufficient direction from maaagement and that the administrative aspects of issuing a charter for this IIT was a formality for which their investigation need not wait.
- 2. Executive management personnel involved in the IIT were well aware of the procedural requirement for a charter.
Due to the concern over EDG operability and the time constraints associated with reaching a conclusion regarding this from the investigation, the failure to issue the charter at the beginning of the IIT was an administrative oversight.
- 3. Personnel knowledgeable of IIT requirements and the issues surrounding the EDG concerns were intimately involved in the investigation being conducted.
They were cognizant of the need for a charter, but were in a fact gathering mode at the time of this recognition.
They proceeded with the understanding that the charter was to be issued soon and was not expected to impact their direction or the activities underway.
4.
Following the Potential Power Transformer failure and fire in EDG "A"
on September 30,
- 1994, Performance Improvement Request (PIR) 94-1680, documented the event and was issued on October 1, 1994.
Since a PIR (i.e.,
a corrective action vehicle) had already been issued after the EDG "A" fire and was open at the time of the similar EDG "B"
fire on October 11, 1994, and given the fact that a formal IIT had already been formed, there was deemed no need for any separate PIR on EDG "B"
in the minds of management personnel involved in this investigation.
This thought process established a
preconceived mind-set that reinforced the lack of concern regarding the fact that no formal charter yet existed.
- 5. Procedure SP 34E-001 requirements for a charter and formal plan for the investigation were essentially buried in the concepts associated with conducting a self assessment.
Self a.esessments, by their very nature, involve a more deliberate thought process for planning and scoping.
Significant events, for which executive management directs the formation of an IIT, already have a heightened sense of urgency, personnel awareness, and management involvement given the need to resolve already known or potentially existing concerns that may have distinct plant safety or other regulatory impact (s).
This factor, coupled with those above, established a lack of importance in the minds of those personnel involved with this IIT regarding the need to fully review the requirements of AP 34E-001, prior to proceeding with the actual conduct of the investigation.
A Attochm:nt to WO 94-0220 Page 3 6/ Procedure AP 34E-001, Revision 1,
"Self Assessment," which included the previous IIT procedural requirements, now also required that a formal plan be issued for significant events under investigatiot This requirement was a departure from previous IIT planning. and resource assignment in that previously only a charter was needed.
In the past, the charter was used to define the basic scope of the investigation and the detailed approach and methodology was subsequently determined during the conduct of the investigation based on the specifica aspeciated with the event.
- Thus, i
procedure AP 34E-001, was somewhat inadequate in that it was not clear that a plan was absolutely required for IITs, although the procedure, if read
[
carefully, did in fact require a plan-for an IIT.
Also, personnel involved had misunderstood this procedural requirement to be applicable only to other types of self assessments (i.e., not IITs).
corrective Stans Taken and Results it h4 avedt l
A formal root cause analysis was performed to encompass the personnel error and procedural aspects of this violation.
The charter for IIT 94-05 was issued on j
October 18, 1994.
Since the final report for IIT 94-05 was issued on October 28, 1994, no formal plan was issued and post IIT performance issuance of a plan was deemed unnecessary.
WCNOC personnel involved with and responsible for the
'l subject IIT have been counseled by the Corporate Self Assessment Coordinator on the current administrative requirements of procedure AP 34E-001.
Corrective Steps That Will Be Taken to Avoid Further Violations:
Procedure AP 34E-001, has been divided into two separate sections to provide clear administrative guidance on (1) IITs (instruction AI 20B-003,
" Incident Investigation Team"); and (2) other types of self assessments (procedure AP 28D-
- 001, "Self Assessment").
The new administrative instruction for IITs will establish, as an IIT Team member, an Investigative Coordinator (IC) position assignment.
The IC's responsibilities will include ensuring that the administrative requirements of this procedure are adhered to by the IIT.
This separation of procedural requirements for IITs and other types of self j
assessments is consistent with past WCNOC practice and will more appropriately focus personnel attention on which requirements are applicable to which types of assessments. These procedures have been approved.
IIT Team Leaders and IC's will be trained on the IIT procedure.
The training will focus on the administrative requirements established in AI 28B-003 and the preferred ~
investigative techniques.
Training is scheduled to commence in February, 1995, i
and will be available on an ongoing basis as needed to enhance and maintain l
personnel understanding and abilities.
If an IIT is initiated prior to the commencement of training in February, 1995, the Team Leader and the IC's will be trained at the beginning of the IIT.
Date When Full C^=pliance Will Be Achieved:
Full compliance with the requirements of Criterion V of Appendix B to 10 CFR 50 has been achieved.
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' Attachment to WO 94-0220 Page 4 L
I l
Violation 482/9413-02:
Failure to implement corrective action requirements in j
I accordance with 10 CFR 50, Appendix B, Criterion XVI, t
- B.
Criterion XVI of Appendix B to 10 CFR Part 50 requires, in part, that i
measures shall be ' established to assure that conditions adverse to quality, such as f ailures, ' malfunctions, deficiencies, deviations, defective material and equipment and nonconformances are promptly identified and corrected.
Licensee Procedure KGP-1210, " Performance.
l Improvement Requests," Revision 10, requires that reported conditions be screened for significance, reportability, and operability.
l tf l
Contrary to the above, the licensee failed to perform an adequate ~
i l
screening for significance, reportability, and operability following I-the "B"
emergency diesel generator static exciter-voltage regulator
-j failure 2 weeks after the near identical
'A" unit failure.
A performance improvement request was not initiated and no documented screening was available during the inspection.
This failure to use the corrective action system as designed resulted in a failure to adequately evaluate the continued operability of the emergency power j
sources with the potential for a known failure mechanism not previously recognized or considered.
Therefore, the operability of both emergency power sources was questionable from October 11, 1994, until administrative controls to assure operability were established just prior to entering Mode 4 on October 24, 1994."
l AA=4 asion of violations Based on a thorough review of the facts surrounding the Emergency Diesel Generator (EDG) static exciter-voltage regulator failures and the subsequent Wolf Creek Nuclear Operating Cooperation (WCNOC) investigation of the failures, as documented in WCNOC Incident Investigation Team (IIT) Report 94-05, WCNOC l-does not agree that it failed to comply with criterion XVI of Appendix B to 10 CFR Part 50.
WCNOC does agree that a failure to meet the requirements of Procedure KGP-1201, j
" Corrective Action," did occur, in that WCNOC did not issue a new Performance l-Improvement Request (PIR) or revise PIR 94-1680 upon the failure of the EDG
- B"
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static exciter-voltage regulator.
WCNOC considers this a violation of Criterion j
l V of Appendix B to 10 CFR Part 50.
j Reason for violations Reason Criterion XVI of Anpendix B to 10 CFR Part 50 wgm not vlolated!
j 10 CFR 50 Appendix B Criterion XVI, " Corrective Action" states " Measures shall be established to assure that conditions adverse to quality, such as failures, i
malfunctions, deficiencies, deviations, defective c.aterial and equipment, and nonconformances are promptly identified and corrected.
In the case of significant conditions adverse to quality, the measures shall assure that the cause of the condition is determined and corrective action taken to preclude repetition.
The identification of the significant condition adverse to quality,
Attechm:nt to WO 94-0220 Page 5 the cause of the condition, and the corrective action taken shall be documented and reported to the appropriate levels of management."
At WCNOC there are three programs utilized to meet the Corrective Action requirements of Criterion XVI.
The first program is utilized to address equipment problems such as failures, malfunctions and defects.
This program is defined in Administrative Procedure ADM 01-057,
- Work Requests".
The second program is utilized to address non-hardware problems such as programmatic or personnel deviations and deficiencies.
This program is defined in General Procedure KGP-1210, " Performance Improvement Requests (PIR's).*
The PIR program is also utilized for the enhancement of safety, availability or efficiency and for hardware failure analysis of significant equipment malfunctions or failurea.
The third program is utilized for systematic incident investigation of management issues or significant events.
This program is currently defined by Administrative Procedure AP 34E-001, "Self Assessment Process."
This program is also utilized to evaluate the effectiveness of organizational and/or program performance.
As a J.esult of the failure of the EDG
- A" Power Potential Transformer (PPT) on September 30, 1994, Work Request (WR) 05098-94 was initiated to identify and correct the transformer failure.
In addition, PIR 94-1680 was initiated for a hardware failure analysis of the transformer fire because of its significance to plant safety.
After a visual inspection of the transformer and a review of the applicable drawings and vendor technical manual, it was concluded that the fire I
was the result of a random equipment failure of the PPT.
It was recommended that the PPT for the EDG
- B" be tested during the upcoming "B"
train outage.
Based upon the initial assessment, it was planned to do further analysis after the refueling outage including a tear down of the failed PPT.
After the failure of the EDG
- B" PPT on October 10, 1994, WR 05374-94 was initiated to identify and correct the equipment failure.
In addition, the Vice President olent Operations requested the initiation of an IIT to be directed by the Vice President Engineering.
The IIT was formed due to the significance of the failed equipment and the potential for a common mode failure mechanism.
Work requests were initiated for both PPT failures in accordance with ADM 01-057 i
which fulfills the requirement for identification of the nonconformances.
The purpose of the IIT was to investigate the transformer failures, determine the root cause (s), recommend corrective actions and to provide the necessary documentation.
The completion of the IIT effort met the requirement for identification of the cause (s), specifying action to preclude recurrence and documentation of significant conditions adverse to quality.
The involvement of the Vice President Plant Operations and Vice President Engineering in the initiation and implementation of the IIT met the requirement for appropriate j
management involvement in the significant condition adverse to quality.
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Therefore all requirements of 10 CFR 50 Appendix B Criterion XVI were met through "he work request and IIT activities.
Procedure ADM 01-057, requires a screening for operability and reportability be performed by the Shift Supervisor.
This evaluation was performed as required for WR 05098-94 and WR 05374-94.
- B" was out of service following the PPT failure and remained out of service during the IIT investigation.
In addition,
i Attcchment to WO 94-0220
)
page 6 as stated in IIT Report 94-05, the operability of the EDG "A"
was uppermost in the minds of the team throughout the investigation and at no time was EDG "A"
considered to be inoperable based upon the known facts at any given moment.
Therefore, although not a requirement of 10 CFR 50 Appendix B Criterion XVI 1
(rather the Technical Specifications and 10 CFR 50.72, 50.73 and 21) operability and reportability were considered for the subject failures both before and throughout the IIT investigation.
The Operations department and the IIT were confident that the "A" EDG remained operable following the "B"
EDG transformer failure.
In addition several conservative actions were taken to minimize the risk while the investigation proceeded.
These actions are consistent with the guidance provided in Generic Letter 91-18, "Information To Licensees Regarding Two NRC Inspection Manual Sections On Resolution Of Degraded And Nonconforming Conditions And On Operability." These actions included:
On October 11, 1994, the Vice President Operations established a administrative requirement which required Operations to obtain his permission prior to lowering the level in the refueling pool below 23 feet above the reactor vessel flange.
- On October 12, 1994, at the request of the IIT, the Shift Supervisor authorized electrical naintenance to check the input fuses to each of the redundant power amplifiers for the "A"
After determining that all input fuses were satisfactory the Shift Supervisor was asked not to operate the EDG's in parallel pending further investigation by the IIT.
The IIT requested that electrical maintenance check the power amplifier fuses after each EDG run.
This requirement was noted on the Operations Outage Turnover sheet until a formal contingency plan was developed and implemented on October 20, 1994.
On October 24, 1994, procedure changes and training were completed for the operators on administrative controls prior to entering MODE 4.
The above described activities following the "B"
EDG transformer failure, demonstrates that operability and plant safety were uppermost in the minds of those involved with the IIT and with the Operations department.
Reason WCNOC failed to follow procedure KGP 1201 Procedure KGP-1210, " Performance Improvement Requests (PIRs)" states that it is to be used for identifying non-hardware problems or potential problems and that it may be used for any concerns or conditions that may improve the safety, availability or ef ficiency of WCNOC.
The failure to initiate a new PIR or to revise the existing PIR, following EDG "B"
PPT failure, does not represent a failure to comply with KGP-1210.
- However, procedure KGP-1201,
" Corrective Action,"
states that cause and corrective action for significant hardware failures are determined, documented and approved by initiating a PIR.
The failure to initiate a PIR following the failure of EDG "B"
PPT was not in full compliance with the requirements of KGP-1201.
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Attachment to WO 94-0220 Page 7 I
Root causet The root cause of WCNOC's failure to follow the procedure is personnel error, in that the responsible personnel.did not have an adequate working knowledge of the programmatic requirements contained within KGP-1201.
Contributing Factors Procedure AP 34E-001 defines the self assessment program used by WCNOC.
The program is utilized for systematic incident investigation of management issues or significant events.
This program is also utilized to evaluate the effectiveness of organizational and/or program performance.
Although the IIT
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process meets the requirements of a corrective Action program, it is not clearly
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identified as such.
The previous IIT procedure revision which combined the IIT process with the self assessment process made it less clear as to the purpose and function of an IIT.
.f Corrective Steps That Have Been T=1ran and &ha Results Reh4evedt WCNOC revised PIR 94-1680 on October 25, 1994, to include the scope of the EDG "B"
PPT failure.
This revision resulted in the PIR being considered-f significant.
The corrective action due date for PIR 94-1680 is January 31, 1995.
Corrective steps That will be Taken to Avoid Further Violations The IIT process has been removed from AP 34E-001.
The process was placed in procedure AI 28B-003,
" Incident Investigation Team."
The
" Incident Investigation Team" procedure includes the requirement to initiate a PIR each I
i time an IIT is formed.
This will cause the elements of corrective action, as required by 10 CFR 50, Appendix B, Criterion XVI, to be located in a program clearly identified as a corrective Action program.
Date when Full Ca=nliance will be Achieved Full compliance with the requirements of Criterion XVI of Appendix B to 10 CFR Part 50 and Criterion V of Appendix B to 10 CFR Part 50 has been achieved.
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